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Meta-Analysis
. 2015 Nov 23;2015(11):CD008351.
doi: 10.1002/14651858.CD008351.pub3.

Airway clearance techniques for bronchiectasis

Annemarie L Lee  1 , Angela T Burge, Anne E Holland
Affiliations
Meta-Analysis

Airway clearance techniques for bronchiectasis

Annemarie L Lee et al. Cochrane Database Syst Rev. .

Abstract

Background: People with non-cystic fibrosis bronchiectasis commonly experience chronic cough and sputum production, features that may be associated with progressive decline in clinical and functional status. Airway clearance techniques (ACTs) are often prescribed to facilitate expectoration of sputum from the lungs, but the efficacy of these techniques in a stable clinical state or during an acute exacerbation of bronchiectasis is unclear.

Objectives: Primary: to determine effects of ACTs on rates of acute exacerbation, incidence of hospitalisation and health-related quality of life (HRQoL) in individuals with acute and stable bronchiectasis. Secondary: to determine whether:• ACTs are safe for individuals with acute and stable bronchiectasis; and• ACTs have beneficial effects on physiology and symptoms in individuals with acute and stable bronchiectasis.

Search methods: We searched the Cochrane Airways Group Specialised Register of trials from inception to November 2015 and PEDro in March 2015, and we handsearched relevant journals.

Selection criteria: Randomised controlled parallel and cross-over trials that compared an ACT versus no treatment, sham ACT or directed coughing in participants with bronchiectasis.

Data collection and analysis: We used standard methodological procedures as expected by The Cochrane Collaboration.

Main results: Seven studies involving 105 participants met the inclusion criteria of this review, six of which were cross-over in design. Six studies included adults with stable bronchiectasis; the other study examined clinically stable children with bronchiectasis. Three studies provided single treatment sessions, two lasted 15 to 21 days and two were longer-term studies. Interventions varied; some control groups received a sham intervention and others were inactive. The methodological quality of these studies was variable, with most studies failing to use concealed allocation for group assignment and with absence of blinding of participants and personnel for outcome measure assessment. Heterogeneity between studies precluded inclusion of these data in the meta-analysis; the review is therefore narrative.One study including 20 adults that compared an airway oscillatory device versus no treatment found no significant difference in the number of exacerbations at 12 weeks (low-quality evidence). Data were not available for assessment of the impact of ACTs on time to exacerbation, duration or incidence of hospitalisation or total number of hospitalised days. The same study reported clinically significant improvements in HRQoL on both disease-specific and cough-related measures. The median difference in the change in total St George's Respiratory Questionnaire (SGRQ) score over three months in this study was 7.5 units (P value = 0.005 (Wilcoxon)). Treatment consisting of high-frequency chest wall oscillation (HFCWO) or a mix of ACTs prescribed for 15 days significantly improved HRQoL when compared with no treatment (low-quality evidence). Two studies reported mean increases in sputum expectoration with airway oscillatory devices in the short term of 8.4 mL (95% confidence interval (CI) 3.4 to 13.4 mL) and in the long term of 3 mL (P value = 0.02). HFCWO improved forced expiratory volume in one second (FEV1) by 156 mL and forced vital capacity (FVC) by 229.1 mL when applied for 15 days, but other types of ACTs showed no effect on dynamic lung volumes. Two studies reported a reduction in pulmonary hyperinflation among adults with non-positive expiratory pressure (PEP) ACTs (difference in functional residual capacity (FRC) of 19%, P value < 0.05; difference in total lung capacity (TLC) of 703 mL, P value = 0.02) and with airway oscillatory devices (difference in FRC of 30%, P value < 0.05) compared with no ACTs. Low-quality evidence suggests that ACTs (HFCWO, airway oscillatory devices or a mix of ACTs) reduce symptoms of breathlessness and cough and improve ease of sputum expectoration compared with no treatment (P value < 0.05). ACTs had no effect on gas exchange, and no studies reported effects of antibiotic usage. Among studies exploring airway oscillating devices, investigators reported no adverse events.

Authors' conclusions: ACTs appear to be safe for individuals (adults and children) with stable bronchiectasis and may account for improvements in sputum expectoration, selected measures of lung function, symptoms and HRQoL. The role of these techniques in acute exacerbation of bronchiectasis is unknown. In view of the chronic nature of bronchiectasis, additional data are needed to establish the short-term and long-term clinical value of ACTs for patient-important outcomes and for long-term clinical parameters that impact disease progression in individuals with stable bronchiectasis, allowing further guidance on prescription of specific ACTs for people with bronchiectasis.

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Conflict of interest statement

None known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Stable bronchiectasis: high‐frequency chest wall oscillation ACT vs no ACT (control), Outcome 1 Change in HRQoL.
1.2
1.2. Analysis
Comparison 1 Stable bronchiectasis: high‐frequency chest wall oscillation ACT vs no ACT (control), Outcome 2 Change in FEV.
1.3
1.3. Analysis
Comparison 1 Stable bronchiectasis: high‐frequency chest wall oscillation ACT vs no ACT (control), Outcome 3 Change in FVC.
1.4
1.4. Analysis
Comparison 1 Stable bronchiectasis: high‐frequency chest wall oscillation ACT vs no ACT (control), Outcome 4 Change in TLC.
1.5
1.5. Analysis
Comparison 1 Stable bronchiectasis: high‐frequency chest wall oscillation ACT vs no ACT (control), Outcome 5 Change in RV.
1.6
1.6. Analysis
Comparison 1 Stable bronchiectasis: high‐frequency chest wall oscillation ACT vs no ACT (control), Outcome 6 Change in PaO2.
1.7
1.7. Analysis
Comparison 1 Stable bronchiectasis: high‐frequency chest wall oscillation ACT vs no ACT (control), Outcome 7 Change in PaCO2.
1.8
1.8. Analysis
Comparison 1 Stable bronchiectasis: high‐frequency chest wall oscillation ACT vs no ACT (control), Outcome 8 Change in breathlessness, cough and sputum.
1.9
1.9. Analysis
Comparison 1 Stable bronchiectasis: high‐frequency chest wall oscillation ACT vs no ACT (control), Outcome 9 Change in MMRC dyspnoea scale.
2.1
2.1. Analysis
Comparison 2 Stable bronchiectasis: chest physiotherapy ACT vs no ACT (control), Outcome 1 Change in HRQoL.
2.2
2.2. Analysis
Comparison 2 Stable bronchiectasis: chest physiotherapy ACT vs no ACT (control), Outcome 2 Change in FEV1.
2.3
2.3. Analysis
Comparison 2 Stable bronchiectasis: chest physiotherapy ACT vs no ACT (control), Outcome 3 Change in FVC.
2.4
2.4. Analysis
Comparison 2 Stable bronchiectasis: chest physiotherapy ACT vs no ACT (control), Outcome 4 Change in TLC.
2.5
2.5. Analysis
Comparison 2 Stable bronchiectasis: chest physiotherapy ACT vs no ACT (control), Outcome 5 Change in RV.
2.6
2.6. Analysis
Comparison 2 Stable bronchiectasis: chest physiotherapy ACT vs no ACT (control), Outcome 6 Change in PaO2.
2.7
2.7. Analysis
Comparison 2 Stable bronchiectasis: chest physiotherapy ACT vs no ACT (control), Outcome 7 Change in PaCO2.
2.8
2.8. Analysis
Comparison 2 Stable bronchiectasis: chest physiotherapy ACT vs no ACT (control), Outcome 8 Change in breathlessness, cough and sputum.
2.9
2.9. Analysis
Comparison 2 Stable bronchiectasis: chest physiotherapy ACT vs no ACT (control), Outcome 9 Change in MMRC dyspnoea scale.
3.1
3.1. Analysis
Comparison 3 Stable bronchiectasis: PEP‐based ACTs vs no ACTs (control), Outcome 1 Sputum volume after 1 session.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Figueiredo 2010 {published data only}
    1. Figueiredo PHS, Zin WA, Guimaraes FS. Flutter valve improves respiratory mechanics and sputum production in patients with bronchiectasis. Physiotherapy Research International 2010;17:12‐20. - PubMed
Guimaraes 2012 {published data only}
    1. Guimaraes FS, Moco VJR, Menezes SLS, Dias CM, Salles REB, Lopes AJ. Effects of ELTGOL and Flutter VRP1 on the dynamic and static pulmonary volumes and on the secretion clearance of patients with bronchiectasis [Efeitos da ELTGOL e do Flutter nos volumes pulmonares dinamicos e estaticos e na remocao de secrecao de pacientes com bronquiectasia]. Revista Brasileira de Fisioterapia 2012;16(2):108‐13. - PubMed
Kurz 1997 {published data only}
    1. Kurz M, Ahrens P, Zielen S, Hofmann D. Physiotherapy with the VRP‐1 device. Objective and subjective results of a comparative study in children with chronic lung diseases [Physiotherapie mit dem VRP1‐Gerat: Objektive und subjektive Ergebnisse einer vergleichenden Studie bei Kindern mit chronischen Lungenerkrankungen]. Pravention und Rehabilitation 1997;9(3):105‐9.
Murray 2009 {published data only (unpublished sought but not used)}
    1. Murray MP, Pentland JL, Hill AT. A randomised crossover trial of chest physiotherapy in non‐cystic fibrosis bronchiectasis. European Respiratory Journal 2009;34(5):1086‐92. - PubMed
Nicolini 2013 {published and unpublished data}
    1. Nicolini A, Cardini F, Landucci N, Lanata S, Ferrari‐Bravo M, Barlascini C. Effectiveness of treatment with high‐frequency chest wall oscillation in patients with bronchiectasis. BMC Pulmonary Medicine 2013;13(21):1‐8. - PMC - PubMed
Sutton 1988 {published data only (unpublished sought but not used)}
    1. Sutton PP, Gemmell HG, Innes N, Davidson J, Smith FW, Legge JS. Use of nebulised saline and nebulised terbutaline as an adjunct to chest physiotherapy. Thorax 1988;43:57‐60. - PMC - PubMed
Svenningsen 2013 {published and unpublished data}
    1. Svenningsen S, Paulin G, Wheatley A, Pike D, Suggett J, McCormack D, et al. Oscillating positive expiratory pressure therapy in chronic obstructive pulmonary disease and bronchiectasis. Chest 2013;144(741A):741.

References to studies excluded from this review

Altiay 2012 {published data only}
    1. Altiay G, Uzmezoglu B, Sut N, Tuna H, Hatipoglu ON. Evaluating flutter device and the active cycle of breathing technique in non‐cystic bronchiectasis: the prospective randomised study. European Respiratory Journal 2012;40(56s):449s.
Ambrosino 1995 {published data only (unpublished sought but not used)}
    1. Ambrosino N, Callegari G, Galloni C, Brega S, Pinna G. Clinical evaluation of oscillating positive expiratory pressure for enhancing expectoration in diseases other than cystic fibrosis. Monaldi Archives for Chest Disease 1995;50(4):269‐75. - PubMed
Antunes 2001 {published data only}
    1. Antunes LC, Carvalho SMF, Borges FD, Assis VL, Godoy I. A study of the conventional chest physiotherapy versus Flutter VRP1 in the treatment of patients carrying bronchiectasis. Salusvita 2001;20(1):23‐30.
Bernabeu Lledo 2014 {published data only}
    1. Bernabeu Lledo M, Atin Arratibel MA, Martinez Tardido M, Gonzalez Cifuentes M, Fuertes Conejo R. Efficacy of respiratory physiotherapy combined with ventilation percussive intrapulmonary (VPI) in stable adult. Annals of Physical and Rehabilitation Medicine 2014;57:e326.
Bilton 2013 {published data only}
    1. Bilton D, Daviskas E, Anderson SD, Kolbe J, King G, Stirling RG, et al. Phase 3 randomized study of the efficacy and safety of inhaled dry powder mannitol for the symptomatic treatment of non‐cystic fibrosis bronchiectasis. Chest 2013;44(1):215‐25. - PubMed
Bradley 2006 {published data only}
    1. Bradley J, Moran F. Pulmonary rehabilitation improves exercise tolerance in patients with bronchiectasis. Australian Journal of Physiotherapy 2006;52(1):65. - PubMed
Briffa 2011 {published data only}
    1. Briffa PJ, Anderson SD, Burton DL, Young IH. Sodium cromoglycate and eformoterol attenuate sensitivity and reactivity to inhaled mannitol in subjects with bronchiectasis. Respirology 2011;16(5):161‐6. - PubMed
Camargo 2013 {published data only}
    1. Camargo AA, Lanza FC, Tupinamba T, Corso SD. Reproducibility of step tests in patients with bronchiectasis. Brazilian Journal of Physical Therapy 2013;17(3):255‐62. - PubMed
Cecins 1999 {published data only}
    1. Cecins N, Jenkins SC, Pengelley J, Ryan G. The active cycle of breathing techniques ‐ to tip or not to tip?. Respiratory Medicine 1999;93(9):660‐5. - PubMed
Cegla 1993 {published data only}
    1. Cegla UH, Retzow A. Physiotherapy in chronic obstructive lung diseases ‐ experiences with the VRP1 Desitin in a multicentre comparative study [Physiotherapie mit dem VRP1 bei chronisch obstruktiven Atemwegserkrankungen ‐ Ergebnisse einer multizentrischen vergleichsstudie]. Pneumologie 1993;47:636‐9. - PubMed
Clinkscale 2012 {published data only}
    1. Clinkscale D, Spihlman K, Watts P, Rosenbluth D, Kollef MH. A randomised trial of conventional chest physical therapy versus high frequency chest wall compressions in intubated and non‐intubated adults. Respiratory Care 2012;57(8):221‐8. - PubMed
Conway 1992 {published data only}
    1. Conway JH, Fleming JS, Perring S, Holgate ST. Humidification as an adjunct to chest physiotherapy in aiding tracheo‐bronchial clearance in patients with bronchiectasis. Respiratory Medicine 1992;86(2):109‐14. - PubMed
Crisafulli 2007 {published data only}
    1. Crisafulli E, Coletti O, Costi S, Zanasi E, lorenzi C, Lucic S, et al. Effectiveness of erdosteine in elderly patients with bronchiectasis and hypersecretion: a 15 days prospective, parallel, open‐label, pilot study. Clinical Therapeutics 2007;29(9):2001‐9. - PubMed
Currie 1988 {published data only}
    1. Currie DC, Greenstone M, Pavia D, Agnew JE, Pellow P, Clarke SW, et al. Efficacy of 'mucoregulatory' agents in Young's syndrome. Thorax 1988;43(6):480‐1. - PMC - PubMed
Daviskas 2008 {published data only}
    1. Daviskas E, Anderson SD, Eberl S, Young IH. Effect of increasing doses of mannitol on mucus clearance in patients with bronchiectasis. European Respiratory Journal 2008;31(4):765‐72. - PubMed
De Diego 2013 {published data only}
    1. Diego A, Milara J, Martinez‐Moragon E, Palop M, Leon M, Cortijo J. Effects of long‐term azithromycin therapy on airway oxidative stress markers innon‐cystic fibrosis bronchiectasis. Respirology 2013;18:1056‐62. - PubMed
Eaton 2007 {published data only}
    1. Eaton T, Young P, Zeng I, Kolbe J. A randomised evaluation of the acute efficacy, acceptability and tolerability of Flutter and active cycle of breathing with and without postural drainage in non‐cystic fibrosis bronchiectasis. Chronic Respiratory Disease 2007;4(1):23‐30. - PubMed
Gallon 1991 {published data only}
    1. Gallon A. Evaluation of chest percussion in the treatment of patients with copious sputum production. Respiratory Medicine 1991;85(1):45‐51. - PubMed
Gastaldi 2011 {published data only}
    1. Gastaldi A, Tambascio J, Lisboa R, Passarelli R, Tatiana L. Effect of the components of Flutter VRP1 on the transport of respiratory secretions in patients with bronchiectasis. World Physical Therapy Conference proceedings 2011;97:eS395‐eS396.
Gokdemir 2014 {published data only}
    1. Gokdemir Y, Karadag‐Saygi E, Erdem E, Bayindir O, Ersu R, Karadag B, et al. Comparison of conventional pulmonary rehabilitation and high‐frequency chest wall oscillation in primary ciliary dyskinesia. Pediatric Pulmonology 2014;49(6):611‐6. - PubMed
Gurses 2013 {published data only}
    1. Gurses HN, Ayhan B, Demir R, Ozyilmaz S. The effects of inspiratory muscle training on respiratory muscle strength and pulmonary functions in children with bronchiectasis. European Respiratory Journal 2013;47(Suppl 57):5064.
Hartsell 1987 {published data only}
    1. Hartsell MB. Chest physiotherapy and mechanical vibration. Journal of Paediatric Nursing 1987;2(2):135‐7. - PubMed
Hasani 1994 {published data only}
    1. Hasani A, Pavia D, Agnew JE, Clarke SW. Regional lung clearance during cough and forced expiration technique (FET): effects of flow and viscoelasticity. Thorax 1994;49(6):557‐61. - PMC - PubMed
Hasani 1995 {published data only}
    1. Hasani A, Toms N, Agnew JE, Pavia D, Clarke SW. Regional mucus clearance following cough and forced expiration technique in patients with asthma, chronic bronchitis and bronchiectasis. European Respiratory Journal Supplement 1995;8:19297.
Herrero 2011 {published data only}
    1. Herrero B, Polverino E, Romeu DM, Vilaro J. Efficacy of airway clearance therapy with different autonomy degrees in nonCF‐bronchiectasis: randomised cross‐over trial. European Respiratory Society 21st Annual Congress; 2011 Sep 24‐28; Amsterdam. 2011; Vol. 38, issue 3:540s (2977).
Herrero 2014 {published data only}
    1. Herrero B, Polverino E, SanMiguel M, Alcaraz V, Marti D, Vilaro J, Torres A. Wet sputum as an objective outcome in a randomized crossover trial in NCF‐BE: Reliability and responsiveness. European Respiratory Journal 2014;44:P4274.
Huang 2014 {published data only}
    1. Huang H, Yang P, Xue J, Tang J, Ding L, Ma Y, Wang J, Guyatt GH, Vannivasingam T, Zhang Y. Evaluating the individualized treatment of traditional Chinese medicine: A pilot study of N‐of‐1 trials.. Evidence‐based Complementary and Alternative Medicine 2014;2014:148730. - PMC - PubMed
Indinnimeo 2007 {published data only}
    1. Indinnimeo L, Tancredi G, Barreto M, Castro G, Zicari AM, Monaco F, et al. Effects of a program of hospital‐supervised chest physical therapy on lung function tests in children with chronic respiratory disease: 1‐year follow‐up. International Journal of Immunopathology and Pharmacology 2007;20(4):841‐5. - PubMed
Joshi 2004 {published data only}
    1. Joshi JM, Sundaram P. Role of inhaled steroids in stable bronchiectasis. Indian Practitioner 2004;57(4):243‐5.
Kaminska 1988 {published data only}
    1. Kaminska TM, Pearson SB. A comparison of postural drainage and positive expiratory pressure in the domiciliary management of patients with chronic bronchial sepsis. Physiotherapy 1988;74(5):251‐4.
Kellett 2005 {published data only}
    1. Kellett F, Redfern J, Niven RM. Evaluation of nebulised hypertonic saline (7%) as an adjunct to physiotherapy in patients with stable bronchiectasis. Respiratory Medicine 2005;99(1):27‐31. - PubMed
Kellett 2011 {published data only}
    1. Kellett F, Robert NM. Nebulised 7% hypertonic saline improves lung function and quality of life in bronchiectasis. Respiratory Medicine 2011;105(4):1831‐5. - PubMed
Larroquet 1997 {published data only}
    1. Larroquet M, Balquet P, Gruner M. Video‐assisted thorascopic surgery for bronchiectasis. Pediatric Pulmonology 1997;24 Suppl 16:180. - PubMed
Lee 2014 {published data only}
    1. Lee AL, Hill CJ, Cecins N, Jenkins S, McDonald CF, Burge AT, et al. The short and long term effects of exercise training in non‐cystic fibrosis bronchiectasis ‐ a randomised controlled trial. Respiratory Research 2014;15(1):1‐10. - PMC - PubMed
Long 2001 {published data only}
    1. Long C. The Effects of Manual Chest Percussion in Patients with Chronic Obstructive Pulmonary Disease and Bronchiectasis. East Sussex Hospitals NHS Trust 2001.
Maa 2007 {published data only}
    1. Maa SH, Tsou TS, Wang KY, Wang CH, Lin HC, Huang YH. Self‐administered acupressure reduces the symptoms that limit daily activities in bronchiectasis patients: pilot study findings. Journal of Clinical Nursing 2007;16(4):794‐804. - PubMed
Mandal 2012 {published data only}
    1. Mandal P, Sidhu MK, Kope L, Pollock W, Stevenson LM, Pentland JL, et al. A pilot study of pulmonary rehabilitation and chest physiotherapy versus chest physiotherapy alone in bronchiectasis. Respiratory Medicine 2012;106(12):1647‐54. - PubMed
Masekela 2013 {published data only}
    1. Masekela R, Anderson R, Gongxeka H, Steel HC, Becker PJ, Green RJ. Lack of efficacy of an immunomodulatory macrolide in childhood HIV related bronchiectasis: a randomised, placebo‐controlled trial. Journal of Antivirals and Antiretrovirals 2013;5(2):44‐9.
Mazzocco 1985 {published data only}
    1. Mazzocco MC, Owens GR, Kirilloff LH, Rogers RM. Chest physiotherapy and postural drainage in patients with bronchiectasis. Chest 1985;88(3):360‐3. - PubMed
Moran 2007 {published data only}
    1. Moran FM, Elborn SE, Bradbury I, Piper A, Hewitt O, Bradley JM. Airway clearance in bronchiectasis: is non‐invasive ventilation a useful adjunct in moderate to severe disease?. Thorax 2007;62 Suppl III:A87.
Morgan 1999 {published data only}
    1. Morgan LC, Maxwell L, Longhi R, Peters MJ, Rutland J. Comparison of Flutter device (FD) with postural drainage (PD) in adult patients with non‐CF bronchiectasis. Proceedings of the Thoracic Society of Australia and New Zealand 1999;52:P93.
Mutalithas 2008 {published data only}
    1. Mutalithas K, Watkin G, Willig B, Wardlaw A, Pavord ID, Birring SS. Improvement in health status following bronchopulmonary hygiene physical therapy in patients with bronchiectasis. Respiratory Medicine 2008;102(8):1140‐4. - PubMed
Nakamura 2003 {published data only}
    1. Nakamura S, Hashimoto Y, Mikami M, Yamanaka E, Soma T, Hino M, et al. Effect of the proteolytic enzyme serrapeptase in patients with chronic airway disease. Respirology 2003;8(3):316‐20. - PubMed
Naraparaju 2010 {published data only}
    1. Naraparaju S, Vaishali K, Venkatesan P, Acharya V. A comparison of the Acapella and a threshold inspiratory muscle trainer for sputum clearance in bronchiectasis ‐ a pilot study. Physiotherapy Theory and Practice 2010;26(6):353‐7. - PubMed
Narayanan 2014 {published data only}
    1. Narayanan A, Meng O, Hyder Ali I A, Izmi M, Ahmad I, Rehab M, et al. A pilot randomized control cross over study evaluating the effectiveness and safety of mechanical percussor compared with conventional chest physiotherapy in adults with productive cough. Medical Journal of Malaysia 2014;69(1):16‐20. - PubMed
Newall 2005 {published data only}
    1. Newall C, Stockley RA, Hill SL. Exercise training and inspiratory muscle training in patients with bronchiectasis. Thorax 2005;60(11):943‐8. - PMC - PubMed
Newton 1979 {published data only}
    1. Newton DA. Chest physiotherapy under scrutiny. Lancet 1979;1(8106):49‐50. - PubMed
Noone 1999 {published data only}
    1. Noone PG, Bennett WD, Regnis JA, Zeman KL, Carson JL, King M, et al. Effect of aerosolized uridine‐5'‐triphosphate on airway clearance with cough in patients with primary ciliary dyskinesia. American Journal of Respiratory and Critical Care Medicine 1999;160(1):144‐9. - PubMed
Osadnik 2014 {published data only}
    1. Osadnik C, Stuart‐Andrews C, Ellis SE, Thompson B, McDonald CF, Holland AE. Positive expiratory pressure via mask does not improve ventilation inhomogeneity more than huffing and coughing in individuals with stable chronic obstructive pulmonary disease and chronic sputum expectoration. Respiration 2014;87(1):38‐44. - PubMed
Paneroni 2011 {published data only}
    1. Paneroni M, Clini E, SImonelli C, Bianchi L, Degli Antoni F, Vitacca M. Safety and efficacy of short‐term intrapulmonary percussive ventilation in patients with bronchiectasis. Respiratory Care 2011;56(7):984‐8. - PubMed
Patterson 2004 {published data only}
    1. Patterson JE, Bradley JM, Elborn JS. Airway clearance in bronchiectasis: a randomized crossover trial of active cycle of breathing techniques (incorporating postural drainage and vibration) versus test of incremental respiratory endurance. Chronic Respiratory Disease 2004;1(3):127‐30. - PubMed
Patterson 2005 {published data only}
    1. Patterson JE, Bradley J, Hewitt O, Bradbury I, Elborn JS. Airway clearance in bronchiectasis: a randomised cross‐over trial of active cycle of breathing techniques versus acapella. Respiration 2005;72:239‐42. - PubMed
Patterson 2007 {published data only (unpublished sought but not used)}
    1. Patterson JE, Hewitt O, Kent L, Bradbury I, Elborn JS, Bradley JM. Acapella versus 'usual airway clearance' during acute exacerbation in bronchiectasis: a randomised crossover trial. Chronic Respiratory Disease 2007;4(2):67‐74. - PubMed
Polverino 2012 {published data only}
    1. Polverino E, Herrero B, Vilaro J, Marti D. Efficacy of airway clearance therapy with different autonomy degrees in non‐CF bronchiectasis: a randomised cross‐over trial. American Journal of Respiratory and Critical Care Medicine 2012;185(1):A4876.
Santamaria 1998 {published data only}
    1. Santamaria F, Celentano L, Buonpensiero P, Sarnelli P, Caterino M, Raia V. Positive expiratory pressure treatment: efficacy in pulmonary diseases. Journal of Pediatrics 1998;133(5):717‐8. - PubMed
Savci 1998 {published data only}
    1. Savci S, Inal D, Arikan H. A comparison of the active cycle of breathing technique with and without manual techniques in patients with bronchiectasis. European Respiratory Journal 1998;1 Suppl 12:28212S.
Su 2012 {published data only}
    1. Su CL, Chang CC, Lin YK, Lee KT, Lee CN, Chiang LL. Randomised crossover study of lung expansion therapy using negative pressure and positive pressure in bronchiectasis. Journal of Experimental and Clinical Medicine 2012;4(7):149‐53.
Sutton 1983 {published data only (unpublished sought but not used)}
    1. Sutton PP, Parker RA, Webber BA, Newman SP, Garland N, Lopez Vidriero MT, et al. Assessment of the forced expiration technique, postural drainage and directed coughing in chest physiotherapy. European Journal of Respiratory Diseases 1983;64(1):62‐8. - PubMed
Syed 2009 {published data only}
    1. Syed N, Maiya AG, Siva Kumar T. Active cycles of breathing technique (ACBT) versus conventional chest physical therapy on airway clearance in bronchiectasis ‐ crossover trial. Advances in Physiotherapy 2009;11(4):193‐8.
Tabernero 2014 {published data only}
    1. Tabernero A, Gil P, Alkiza R, Garros J, Hernandez A, Artola JL. Inhaled colistin in elderly patients with non‐cystic fibrosis bronchiectasis and chronic Pseudomonas aeruginosa (PA) bronchial infection. Chest 2014;145(Suppl 3):431A.
Tabernero Huguet 2015 {published data only}
    1. Tabernero Huguet E, Gil Alana P, Alkiza Basanez R, Hernandez Gil A, Garros Garay J, Artola Igarza JL. Inhaled colistin in elderly patients with non‐cystic fibrosis bronchiectasis and chronic Pseudomonas aeruginosa bronchial infection [Tratamiento inhalado con colistina a largo plazo en pacientes ancianos con infeccion cronica por Pseudomonas aeruginosa y bronquiectasias]. Revista Espanola de Geriatria y Gerontologia 2015;50:111‐5. - PubMed
Tambascio 2011 {published data only}
    1. Tambascio J, Souza LT, Lisboa RMh, Passarelli RDCV, Souza HCD, Gastaldi AC. The influence of Flutter VRP1 components of mucus transport of patients with bronchiectasis. Respiratory Medicine 2011;105(9):1316‐21. - PubMed
Tambascio 2014 {published data only}
    1. Tambascio J, Baddini‐Martinez JA, Passarelli CV, Goncalves EC, Miranda APB, Martinez R, Gastaldi AC. Effects of Flutter ® VRP1 on inflammatory profile, microbiology and transport indexes of respiratory secretions of patients with bronchiectasis.. American Journal of Respiratory and Critical Care Medicine 2014;189:A6260.
Thompson 2002 {published data only}
    1. Thompson CS, Harrison S, Ashley J, Day K, Smith DL. Randomised crossover study of the Flutter device and the active cycle of breathing technique in non‐cystic fibrosis bronchiectasis. Thorax 2002;57(5):446‐8. - PMC - PubMed
Tsang 1994 {published data only}
    1. Tsang KWT, Roberts P, Read RC, Kees R, Wilson R, Cole PJ. The concentrations of clarithromycin and its 14‐hydroxy metabolite in sputum of patients with bronchiectasis following single dose administration. Journal of Antimicrobial Chemotherapy 1994;33(2):289‐97. - PubMed
Tsang 2003 {published data only (unpublished sought but not used)}
    1. Tsang SMH, Jones AYM. Postural drainage or flutter device in conjunction with breathing and coughing compared to breathing and coughing alone in improving secretion removal and lung function in patients with acute exacerbation of bronchiectasis. A pilot study. Hong Kong Physiotherapy Journal 2003;21:29‐36.
Valente 2004 {published data only}
    1. Valente AM, Gastaldi AC, Cravo SL, Afonso JL, Sologuren MJJ, Guimaraes RC. The effect of two techniques on the characteristics and transport of sputum in patients with bronchiectasis. A pilot study. Physiotherapy 2004;90(3):158‐64.
Venturelli 2013 {published data only}
    1. Venturelli E, Crisafulli E, deBiase A, Righi D, Berrighi D, Cavicchioli PP, et al. Efficacy of temporary positive expiratory pressure (TPEP) in patients with lung diseases and chronic mucus hypersecretion. The UNIKO(R) project: a multicentre randomized controlled trial. Clinical Rehabilitation 2013;27(4):336‐46. - PubMed
Volker 1972 {published data only}
    1. Volker C. Objectivation of treatment effects in children with respiratory tract diseases using spirometric examinations in the people's saline bath resort, Kosen. Zeitschrift Fur Physiotherapie 1972;24(5):383‐90. - PubMed
Wilson 1995 {published data only}
    1. Wilson GE, Baldwin AL, Walshaw MJ. A comparison of traditional chest physiotherapy with the active cycle of breathing in patients with chronic suppurative lung disease. European Respiratory Journal 1995;8 Suppl 19:171S.
Yilva 2015 {published data only}
    1. Silva Y, Greer T, Farah C, Li F, Morgan L. Lung flute is comparable to flutter device for sputum clearance in adults with non‐cystic fibrosis bronchiectasis. Respirology 2015;20:114(TP 143).

References to studies awaiting assessment

NCT00700388 {published data only}
    1. NCT00700388. Efficacy of temporary positive expiratory pressure (TPEP) in chronic hypersecretion (UNIKO). https://clinicaltrials.gov/ct2/show/ (accessed 10 April 2015).
NCT01112410 {published data only}
    1. NCT01112410. Hypertonic saline (6%) versus isotonic saline (0.9%) in bronchiectasis. https://clinicaltrials.gov/ct2/show/NCT01112410 (accessed 10 April 2015).
NCT01209546 {published data only}
    1. NCT01209546. Study of the effect of FLUTTER® VRP1 (PEP and Oscillating High Frequency). (FLUTTER®VRP1). https://clinicaltrials.gov/ct2/show/NCT01209546 (accessed 10 April 2015).

References to ongoing studies

ACTRN12610000078055 {published data only}
    1. ACTRN12610000078055. Acute effect of slow expiration with the glottis open in lateral posture ("expiration lente totale glotte ouverte en infralatéral", ELTGOL) and huff on physical properties of sputum from patients with bronchiectasis: a pilot study. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=335040 (accessed 2 July 2015).
ACTRN12614001072606 {published data only}
    1. ACTRN12614001072606. Evaluating the ease of secretion clearance with flutter device compared to lung Flute in patients with bronchiectasis. WHO Clinical Trials 2013.
ACTRN12614001233617 {published data only}
    1. ACTRN12614001233617. Does the bubble­‐positive expiratory pressure (PEP) device improve secretion clearance compared to the active cycle of breathing technique (ACBT) or no intervention (control) in people with non­‐cystic fibrosis bronchiectasis?. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=1261... (accessed 3 July 2015).
NCT00452114 {published data only}
    1. NCT00452114. In‐exsufflator cough assist device in patients with symptomatic bronchiectasis. https://clinicaltrials.gov/ct2/show/NCT00452114 (accessed 10 April 2015).
NCT01480882 {published data only}
    1. NCT01480882. Efficacy and safety study of a percussion device to mobilise sputum from respiratory passage (LEGA). https://clinicaltrials.gov/ct2/show/NCT01480882 (accessed 10 April 2015).
NCT01578681 {published data only}
    1. NCT01578681. ELTGOL and bronchiectasis. Respiratory therapy (ELTGOLBQ). https://clinicaltrials.gov/ct2/show/NCT01578681 (accessed 10 April 2015).
NCT01854788 {published data only}
    1. NCT01854788. 3 airway clearance techniques in non cystic fibrosis bronchiectasis. https://clinicaltrials.gov/ct2/show/NCT01854788 (accessed 10 April 2015).
NCT01929356 {published data only}
    1. NCT01929356. Chest physiotherapy and lung function in primary ciliary dyskinesia. https://clinicaltrials.gov/ct2/show/NCT01929356 (accessed 10 April 2015).
NCT02324855 {published data only}
    1. NCT02324855. Long‐term airway clearance therapy in non‐cystic fibrosis bronchiectasis. https://clinicaltrials.gov/ct2/show/NCT02324855 (accessed 10 April 2015).

Additional references

AIHW 2005
    1. Australian Institute of Health and Welfare. Chronic Respiratory Diseases in Australia: Their Prevalence, Consequences and Prevention. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442459693 (accessed 3 July 2015).
Arens 1994
    1. Arens RA, Gozal D, Omlin KJ, Vega J, Boyd KP, Keens TG, et al. Comparison of high frequency chest compression and conventional chest physiotherapy in hospitalised patients with cystic fibrosis. American Journal of Respiratory and Critical Care Medicine 1994;114:171‐7. - PubMed
Barker 2002
    1. Barker A. Medical progress: bronchiectasis. New England Journal of Medicine 2002;346(18):1383‐93. - PubMed
Bateman 1981
    1. Bateman J, Newman S, Daunt K, Sheahan N, Pavia D, Clarke S. Is cough as effective as chest physiotherapy in the removal of excessive tracheobronchial secretions?. Thorax 1981;36:683‐7. - PMC - PubMed
Bott 2009
    1. Bott J, Blumenthal S, Buxton M, Ellum S, Falconer C, Garrod R, et al. Guidelines for the physiotherapy management of the adult medical, spontaneously breathing patient. Thorax 2009;64 Suppl 1:i1‐i51. - PubMed
Boucher 2010
    1. Boucher RC. Bronchiectasis: a continuum of ion transport dysfunction or multiple hits?. American Journal of Respiratory and Critical Care Medicine 2010;181:1017‐9. - PubMed
Braveman 2007
    1. Braveman J, Nozzarella M. High‐frequency chest compression advanced therapy for obstructive lung disease. Respiratory Therapy 2007;2(48):51.
Chang 2008
    1. Chang A, Bilton D. Exacerbations of cystic fibrosis: 4 Non‐cystic fibrosis bronchiectasis. Thorax 2008;63:269‐76. - PubMed
Chang 2015
    1. Chang AB, Bell SC, Torzillo PJ, King PT, Maguire GP, Byrnes CA, et al. Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand Thoracic Society of Australia and New Zealand guidelines. Medical Journal of Australia 2015;202(1):21‐3. - PubMed
Cochrane 1977
    1. Cochrane GM, Webber BA, Clarke SW. Effect of sputum on pulmonary function. British Medical Journal 1977;2:1181‐3. - PMC - PubMed
Cole 1986
    1. Cole PJ. Inflammation: a two‐edged sword ‐ the model of bronchiectasis. European Journal of Respiratory Disease ‐ Supplement 1986;147:6‐15. - PubMed
Elborne 2007
    1. Elborne JS, Bell S. Pulmonary exacerbations in cystic fibrosis and bronchiectasis. Thorax 2007;62(4):288‐90. - PMC - PubMed
Flude 2012
    1. Flude LJ, Agent P, Bilton D. Chest physiotherapy techniques in bronchiectasis. Clinics in Chest Medicine 2012;33(2):351‐61. - PubMed
Flume 2009
    1. Flume PA, Robinson KA, O'Sullivan BP, Finder JD, Vender RL, Willey‐Courand DB. Cystic fibrosis pulmonary guidelines: airway clearance therapies. Respiratory Care 2009;54:522‐37. - PubMed
Gaga 1998
    1. Gaga M, Bentley AM, Humbert M, Barkans J, O'Brien F, Wathens CG, et al. Increases in CD4+ T lymphocytes, macrophages, neutrophils and interleukin 8 positive cells in the airways of patients with bronchiectasis. Thorax 1998;53(8):685‐91. - PMC - PubMed
Garrard 1978
    1. Garrard CS, Shah M. The effects of expiratory positive airway pressure on functional residual capacity in normal subjects. Critical Care Medicine 1978;6:320‐2. - PubMed
Goeminne 2012
    1. Goeminne PC, Scheers H, Decraene A, Seys S, Dupont LJ. Risk factors for morbidity and death in non‐cystic fibrosis bronchiectasis: a retrospective cross‐sectional analysis of CT diagnosed bronchiectatic patients. Respiratory Research 2012;13:21. - PMC - PubMed
Hansen 1994
    1. Hansen LG, Warwick WJ, Hansen KL. Mucus transport mechanisms in relation to the effect of high frequency chest compression (HFCC) on mucus clearance. Pediatric Pulmonology 1994;17:113‐8. - PubMed
Higgins 2011
    1. Higgins J, Altman D (editors). Chapter 8: Assessing risk of bias in included studies. In: HigginsJPT, Green S (editors). Cochrane Handbook of Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. www.cochrane‐handbook.org.
Hill 2011
    1. Hill AT, Pasteur M, Cornford C, Welham S, Bilton D. Primary care summary of the British Thoracic Society guideline on the management of non‐cystic fibrosis bronchiectasis. Primary Care Respiratory Journal 2011;20(2):135‐40. - PMC - PubMed
Horsley 2008
    1. Horsley A, Gustafsson P, Macleod K, Saunders C, Greening AP, Porteus DJ, et al. Lung clearance index is a sensitive, repeatable and practical measure of airway disease in adults with cystic fibrosis. Thorax 2008;63:135‐40. - PubMed
Isabey 1984
    1. Isabey D, Harf A, Chang HK. Alveolar ventilation during high‐frequency oscillation: core dead space concept. Journal of Applied Physiology 1984;56:700‐7. - PubMed
Jones 2005
    1. Jones PW. St George's Respiratory Questionnaire. Journal of Chronic Obstructive Pulmonary Disease 2005;2(11):75‐9. - PMC - PubMed
Kempainen 2010
    1. Kempainen RR, Milla C, Dunitz J, Savik K, Hazelwood A, Williams C, et al. Comparison of settings used for high‐frequency chest wall compression in cystic fibrosis. Respiratory Care 2010;55:695‐701. - PubMed
Kim 1986
    1. Kim C, Rodriguez C, Eldridge M, Sackner M. Criteria for mucus transport in the airways by two‐phase gas‐liquid flow mechanism. Journal of Applied Physiology 1986;60(3):901‐7. - PubMed
Kim 1987
    1. Kim C, Iglesias A, Sackner M. Mucus clearance by two‐phase gas‐liquid flow mechanism: asymmetric periodic flow model. Journal of Applied Physiology 1987;62(3):957‐71. - PubMed
King 2005
    1. King P, Holdsworth SR, Freezer NJ, Villanueva E, Gallagher M, Holmes PW. Outcome in adult bronchiectasis. Journal of Chronic Obstructive Pulmonary Disease 2005;2:27‐34. - PubMed
King 2006a
    1. King P, Holdsworth SR, Freezer NJ, Holmes PW. Bronchiectasis. Internal Medicine Journal 2006;36:729‐37. - PubMed
King 2006b
    1. King P, Holdsworth SR, Freezer NJ, Villanueva E, Holmes PW. Characterisation of the onset and presenting clinical features of adult bronchiectasis. Respiratory Medicine 2006;100(12):2183‐9. - PubMed
King 2010
    1. King PT, Daviskas E. Management of bronchiectasis. Breathe 2010;6:353‐60.
Koulouris 2003
    1. Koulouris NG, Retsou S, Kosmas E, Dimakou K, Malagari K, Mantzikopoulos G, et al. Tidal expiratory flow limitation, dyspnoea and exercise capacity in patients with bilateral bronchiectasis. European Respiratory Journal 2003;21:743‐8. - PubMed
Langendam 2013
    1. Langendam M, Akl EA, Dahm P, Glasziou P, Guyatt G, Schunemann HJ. Assessing and presenting summaries of evidence in Cochrane reviews. Systematic Reviews 2013;2(81):1‐9. - PMC - PubMed
Loebinger 2009
    1. Loebinger M, Wells A, Hansell D, Chinyanganya N, Devaraj A, Meister M, et al. Mortality in bronchiectasis: a long‐term study assessing the factors influencing survival. European Respiratory Journal 2009;34:843‐9. - PubMed
Martinez‐Garcia 2005
    1. Martinez‐Garcia MA, Perpina‐Tordera M, Roman‐Sanchez P, Soler‐Cataluna JJ. Quality‐of‐life determinants in patients with clinically stable bronchiectasis. Chest 2005;128(2):739‐45. - PubMed
Martinez‐Garcia 2007
    1. Martinez‐Garcia MA, Soler‐Cataluna JJ, Perpina‐Tordera M, Roman‐Sanchez P, Soriano J. Factors associated with lung function decline in adult patients with stable non‐cystic fibrosis bronchiectasis. Chest 2007;132:1565‐72. - PubMed
Martinez‐Garcia 2007a
    1. Martinez‐Garcia MA, Perpina‐Tordera M, Soler‐Cataluna JJ, Roman‐Sanchez P, Lloris‐Bayo A, Gonzalez‐Molina A. Dissociation of lung function, dyspnoea ratings and pulmonary extension in bronchiectasis. Respiratory Medicine 2007;101:2248‐53. - PubMed
McCool 2006
    1. McCool FD, Rosen MJ. Nonpharmacologic airway clearance therapies: ACCP evidence‐based clinical practice guidelines. Chest 2006;129 Suppl 1:250S‐259S. - PubMed
McShane 2013
    1. McShane PJ, Naureckas ET, Tino G, Strek ME. Non‐cystic fibrosis bronchiectasis. American Journal of Respiratory and Critical Care Medicine 2013;188:647‐56. - PubMed
Neves 2011
    1. Neves PC, Guerra M, Ponce P, Miranda J, Vouga L. Non‐cystic fibrosis bronchiectasis. Interactive Cardiovascular and Thoracic Surgery 2011;13:619‐25. - PubMed
O'Donnell 1998
    1. O'Donnell AE, Barker AF, Ilowite JS, Fick RB and the rhDNAse Study Group. Treatment of idiopathic bronchiectasis with aerosolized recombinant human DNAse I. rhDNAse Study Group. Chest 1998;113:1329‐34. - PubMed
Oberwaldner 1986
    1. Oberwaldner B, Evans JC, Zach MS. Forced expirations against a variable resistance: a new physiotherapy method in cystic fibrosis. Pediatric Pulmonology 1986;2:358‐67. - PubMed
Onen 2007
    1. Onen ZP, Gulbay EB, Sen E, Yildiz OA, Saryal S, Acican T, Karabiyikoglu G. Analysis of the factors related to mortality in patients with bronchiectasis. Respiratory Medicine 2007;101:1390‐7. - PubMed
Pasteur 2010
    1. Pasteur MC, Bilton D, Hill AT, British Thoracic Society Bronchiectasis non‐CF Group. British Thoracic Society guideline for Non‐CF Bronchiectasis. Thorax 2010;65 Suppl 1:i1‐58. - PubMed
Prasad 2007
    1. Prasad SA. Airway clearance techniques. Which one?. Chronic Respiratory Disease 2007;4:65‐6. - PubMed
Raj 2009
    1. Raj AA, Pavoord DI, Birring SS. Clinical cough IV: What is the minimal important difference for the Leicester Cough Questionnaire?. Handbook of Experimental Pharmacology 2009;187:311‐20. - PubMed
Regnis 1994
    1. Regnis JA, Robinson M, Bailey DL, Cook P, Hooper P, Chan HK, et al. Mucociliary clearance in patients with cystic fibrosis and in normal subjects. American Journal of Respiratory and Critical Care Medicine 1994;150:66‐71. - PubMed
RevMan 2015 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2015.
Schunemann 2008
    1. Schunemann JH, Oxman AD, Vist GE, Higgins J, Deeks J, Glasziou P, et al. Chapter 12: Interpreting results and drawing conclusions. In: HigginsJPT, Green S (editors). Cochrane Handbook of Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. www.cochrane‐handbook.org.
Sutton 1985
    1. Sutton P, Lopez‐Vidriero M, Pavia D, Newman S, Clay M, Webber B, et al. Assessment of percussion, vibratory‐shaking and breathing exercises in chest physiotherapy. European Journal of Respiratory Disease 1985;66(2):147‐52. - PubMed
Tsang 2004
    1. Tsang K, Tipoe G. Bronchiectasis: not an orphan disease of the East. International Journal of Tuberculosis and Lung Disease 2004;8(6):691‐702. - PubMed
Tsang 2009
    1. Tsang KW, Bilton D. Clinical challenges in managing bronchiectasis. Respirology 2009;14:637‐50. - PubMed
van der Schans 2000
    1. Schans CP, Prasad A, Main E. Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis. Cochrane Database of Systematic Reviews 2000, Issue 2. [DOI: 10.1002/14651858.CD001401] - DOI - PubMed
van der Schans 2002
    1. Schans CP. Airway clearance: assessment of techniques. Paediatric Respiratory Reviews 2002;3:110‐4. - PubMed
van Henstrum 1988
    1. Henstrum M, Festen J, Beurskens C, Hankel M, Beekman F, Corstens F. Conventional physiotherapy and forced expiration manoeuvres have similar effects on tracheobronchial clearance. European Respiratory Journal 1988;1:758‐61. - PubMed
Weycker 2005
    1. Weycker D, Edelsberg J, Oster G, Tino G. Prevalence and economic burden of bronchiectasis. Clinical Pulmonary Medicine 2005;12(4):205‐9.
Williams 1994
    1. Williams MT. Chest physiotherapy and cystic fibrosis. Why is the most effective form of treatment still unclear?. Chest 1994;1006:1872‐82. - PubMed
Wilson 1997
    1. Wilson C, Jones P, O'Leary CJ, Cole P, Wilson R. Validation of the St George's Respiratory Questionnaire in bronchiectasis. American Journal of Respiratory and Critical Care Medicine 1997;156:536‐41. - PubMed

References to other published versions of this review

Jones 1998
    1. Jones AP, Rowe BH. Bronchopulmonary hygiene physical therapy for chronic obstructive pulmonary disease and bronchiectasis. Cochrane Database of Systematic Reviews 1998, Issue 4. [DOI: 10.1002/14651858.CD000045] - DOI - PubMed
Lee 2013
    1. Lee AL, Burge AT, Holland AE. Airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews 2013, Issue 5. [DOI: 10.1002/14651858.CD008351.pub2] - DOI - PubMed